Prostate Cancer UK PSA testing guideline

Consensus statements on prostate-specific antigen testing in asymptomatic men in the UK

Introduction

The 13 consensus statements below (in bold bulleted text), provide additional guidance to Public Health England’s Prostate Cancer Risk Management Programme (PCRMP), and aim to drive improvements in the early detection of prostate cancer in men without symptoms while aiming to avoid over treatment and reduce variation in practice

Methods

A web-based Delphi process, comprising 3 questionnaire rounds, was conducted to form consensus recommendations in relation to prostate-specific antigen (PSA) testing in asymptomatic men, in areas where high quality, published evidence was lacking. Consensus in the responses was defined as an agreement from at least 70% from the respondents

The consensus statements have been endorsed by the British Association of Urological Nurses (BAUN), the British Association of Urological Surgeons (BAUS) and the Primary Care Urology Society (PCUS)

Statement 1

A man’s PSA level should be built into a validated risk assessment tool, when available, alongside other known risk factors to better assess a man’s risk of prostate cancer and aid in the decision-making process

Prostate Cancer UK is working with international experts to change the way prostate cancer is diagnosed across the UK by developing a risk prediction tool for primary care practice

Statement 2

Primary healthcare professionals need to be aware of the factors that put men at higher than average risk of prostate cancer

Increasing age, Black ethnicity, and a family history of prostate cancer put men at higher than average risk of prostate cancer

Statement 3

Primary healthcare professionals need to be prepared to have proactive conversations with men at higher than average risk of prostate cancer about prostate cancer risk and the PSA test

Statement 4

Governments and public health agencies have primary responsibility for raising awareness of prostate health and prostate cancer risk factors among men in the UK, with relevant contribution from healthcare professionals and charities

The use of targeted messaging should be considered

Statement 5

All men should be able to access PSA testing from the age of 50, but men at higher than average risk of prostate cancer should be able to access the PSA test from the age of 45

The PCRMP guidance states that ‘The PSA test is available free to any man aged 50 or over who requests it, after careful consideration of the implications’

Statement 6

When a PSA test is being considered, primary healthcare professionals should provide balanced information on the pros and cons of the PSA test in order to allow the man to make up his own mind on whether to have the test

Information on the pros and cons of the PSA test can be found in the PCRMP guidance, and on the Prostate Cancer UK information page on the PSA test

Statement 7

Asymptomatic men with a life expectancy clearly less than 10 years should be recommended against an initial or repeat PSA test as they are unlikely to benefit

Statement 8

GPs should offer a digital rectal examination (DRE) to all asymptomatic men who have decided to have a PSA test

Statement 9

Asymptomatic men at higher than average risk of prostate cancer who have a PSA test between the ages of 45 and 49 should be referred for further investigations if their PSA level is higher than 2.5 ng/ml

This recommendation is based on the limited evidence currently available, and may need to be reviewed if further information becomes available

Statement 10

PSA history and a rising PSA (whilst still under the referral threshold) should be taken into consideration when deciding whether to refer to secondary care

The PCRMP states the new recommended prostate biopsy referral value for men aged 50–69 years is ≥3 ng/ml

Statement 11

Asymptomatic men who have a PSA level below the threshold referral value for their age should not be denied a repeat PSA test. Re-testing intervals should be individualised following a discussion incorporating prostate cancer risk factors

Statement 12

Asymptomatic men over 40 should consider a single ‘baseline’ PSA test to help predict their future prostate cancer risk

If the PSA level is above the age-specific median value, they should be considered at higher than average risk of prostate cancer and should be encouraged to be re-tested in the future